Healthcare Provider Details

I. General information

NPI: 1790762748
Provider Name (Legal Business Name): SUSAN E. HAMMON ANP
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 12/29/2005
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

MAGTFTC MCAGCC BOX 788250
TWENTYNINE PALMS CA
92278-8250
US

IV. Provider business mailing address

1081 N CHINA LAKE BLVD
RIDGECREST CA
93555-3130
US

V. Phone/Fax

Practice location:
  • Phone: 760-830-2194
  • Fax:
Mailing address:
  • Phone: 760-499-3899
  • Fax: 760-499-3393

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WX0106X
TaxonomyOccupational Health Registered Nurse
License Number78225
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: